	Opioid Treatment

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

OTP 4: Service Planning and Monitoring

Every person participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

OTP 4.01

A service plan is developed in a timely manner with the full participation of the service recipient, and expedited service-planning is available when crisis or urgent need is identified.

Interpretation: Service planning is conducted so that the service recipient retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions.

OTP 4.02

A family-centered service plan is developed with the participation of the individual’s family and/or significant others when agreed to by the person.

OTP 4.03

The service plan is based on the assessment, and includes:

agreed upon goals, including education, vocational, and employment goals, desired outcomes, and timeframes for achieving them;
recommendations for medical, psychosocial, economic, legal, or other support services and by whom they will be provided; and
the service recipient’s signature.

OTP 4.04

During the service planning process the organization explains:

available options;
how the organization can support the achievement of desired outcomes; and
the benefits, alternatives, and risks or consequences of planned services.

OTP 4.05

The service plan addresses, as appropriate:

unmet service and support needs;
possibilities for maintaining and strengthening family relationships; and
the need for support of the individual’s informal social network.

OTP 4.06

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:

service plan implementation;
progress toward achieving goals and desired outcomes; and
the continuing appropriateness of the service goals.

Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker's supervisor reviews a sample of the worker's evaluations as per the requirements of the standard.

Timeframes for review should be adjusted depending upon: issues and needs of persons receiving services and frequency and intensity of services provided.

OTP 4.07

The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.

OTP 4.08

Family members and significant others, as appropriate and with the consent of the individual, may be invited to participate in case conferences and may be advised of ongoing progress.

Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation or including them in scheduling decisions.

QUICK JUMP TO


	PURPOSE: Individuals who participate in Opioid Treatment Programs improve social, emotional, and vocational functioning, achieve optimal productivity, and attain the recovery they seek.

RELATED FILES


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	SERVICE PLAN A written plan of action based on the assessment of consumer needs and strengths that identifies problems, sets goals, and describes a strategy for achieving those goals and engaging in joint problem solving with the consumer. Also known as a "treatment plan".


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	SERVICE GOALS Broad, issue-oriented statements that reflect the realistic achievements to be accomplished in the short or long term. Goals are achieved through the accomplishment of specific quantifiable objectives.


	SAMPLE A portion or representative percentage of a greater whole.


	EVALUATION The review and assessment of organizational operations, programs and services.


	LEGAL GUARDIAN A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.